Plummer-Vinson Syndrome in a Crohn’s disease patient

Plummer Vinson Syndrome (PVS), a rare condition complicating iron deficiency anaemia, manifests as a classic triad of dysphagia, anaemia and oesophageal web. Iron deficiency is the commonest systematic complication of Crohn’s disease with only one described case of a Crohn’s disease patient combined with PVS in the literature. We present a case of PVS complicating Crohn’s disease in a 38-years-old female patient under treatment with the biologic agent Ustekinumab (human interleukin 12/23 monoclonal antibody) suffering from a progressively worsening dysphagia.     

Rheumatoid vasculitis with multiple intestinal ulcerations: report of a case]

Rheumatoid vasculitis is a relatively uncommon complication of rheumatoid arthritis (RA). It shows wide variety of extra-articular features including skin and neurologic involvement, but rarely shows gastrointestinal involvement. We describe a 79-old-man of rheumatoid vasculitis manifesting as small bowel multiple ulcerations accompanied by perforation of the descending colon diverticulum. The patient was admitted to our hospital with rectal bleeding and severe anemia. He had had rheumatoid arthritis for more than 10 years with treatment of non-steroidal anti-inflammatory drugs (NSAIDs) and low-dose prednisone. Upper endoscopy or colonoscopy revealed no evidence of bleeding. Suddenly he developed cramping abdominal pain, and emergency operation was performed. Segments of the descending colon and small bowel were resected to reveal perforation of the descending diverticulum and severe multiple ulcer of small bowel. The pathological examination showed multiple ulcerations of the small intestine was caused by vasculitis.     

胶囊内镜滞留临床特征及处置策略

目的探讨胶囊内镜滞留的临床特征及处理。方法回顾性分析2008年9月-2013年9月行胶囊内镜检查中出现胶囊滞留的病例特征。结果 559例胶囊内镜检查中,共发生胶囊滞留11例,发生率为2.0%,9例为克罗恩病,2例为小肠肿瘤;其中2例因并发肠梗阻、1例并发消化道穿孔行手术治疗,1例小肠镜下取出胶囊,1例4个月后自行排出,4例仍在继续随访中,无胶囊滞留相关的死亡病例。结论胶囊滞留是胶囊内镜检查中较严重并发症,应尽可能在内镜下取出胶囊或行手术治疗。     

Left hydronephrosis caused by Crohn disease successfully treated conservatively

We report the case of a 35-year-old man who presented with fever, diarrhea, and a left abdominal mass. Diagnostic studies confirmed Crohn disease and revealed an abdominal mass obstructing the left ureter with hydroureter and hydronephrosis. The patient was successfully treated conservatively, with corticosteroids and mesalamine, A review of the literature indicates a predominance of right ureteral involvement in Crohn disease, associated with a high incidence of ileocecal disease. Most of these patients were treated surgically, with resection of ileocecal lesion and/or ureterolysis. Ureteral obstruction as a complication of Crohn disease is discussed, with emphasis on conservative treatment.     

A case of Non-Hodgkin's lymphoma in a patient with Crohn's disease]

Although adenocarcinoma is a well known complication of chronic inflammatory bowel disease, primary gastrointestinal lymphoma occurring in Crohn's disease is rare. A 40-year-old man with 10 year-history of Crohn's disease had multiple longitudinal ulcerative lesions on descending colon in follow-up colonoscopic examination. Microscopic examination of proximal descending colon revealed peripheral T cell lymphoma and other site of the descending colon was consistent with Crohn's disease. The patient reached complete remission of malignant lymphoma after three cycles of combined chemotherapy. He has been well for 10 months with sulfasalazine maintenance therapy but was admitted to the hospital due to spontaneous bowel perforation of ascending colon. Right hemicolectomy was done, but the patient died of post-surgical recurrent mesenteric abscess and sepsis. To the best of our knowledge, this is the first case of Non-Hodgkin's lymphoma complicating Crohn's disease in Korea which was confirmed by immunohistochemical studies.     

Double sténose gastrique et duodénale révélant une maladie de Crohn (à propos d’un cas)

Abstract

Gastric and duodenal in Crohn’s disease is rare. We report an exceptional case of double gastric and duodenal stenosis revealing a Crohn’s disease, we define its epidemiological, clinical, therapeutic and evolutive caracteristics.

Case report

patient, 25 years old, followed since 2004 for chronic diarrhea, was wrongly treated for intestinal tuberculosis without clinical improvement, Crohn’s disease was diagnosed on the following arguments.

Clinical

presence of postprandial food vomiting, a feeling of fullness, two episodes of of low abundance hematemesis and epigastric pain.

Endoscopic and histological

an oesogastroduodénale endoscopy showed erythematous gastritis, gastric stenosis, micronodular duodenal mucosa. Gastric biopsy revealed noncaseating granulomas. Colonoscopy was normal. Colonic biopsy found a noncaseating granulomas. Radiology: The upper gastrointestinal transit found a gastric and duodenal stasis and short, regular antral stenosis. The SBFT showed a duodenal stenosis. The patient was treated with corticosteroids, immunosuppressive drugs and proton pump inhibitor with a good clinical and biological evolution.     

A case of Behçet's disease accompanied by colitis with longitudinal ulcers and granuloma

A 37‐year‐old female presenting with oral and genital ulcers and erythema nodosum on both arms was diagnosed as having Behçet’s disease. The symptoms resolved spontaneously. However, she was admitted to our hospital (Keio University Hospital) several months later because of fever, aphthous ulcers of the oral cavity, lower abdominal pain and frequent diarrhea. A colonoscopic examination revealed multiple ulcers including longitudinal ulcers in the ascending and transverse colon, and histological examination of biopsied specimens demonstrated non‐caseating epithelioid granuloma. Treatment with prednisolone and 5‐aminosalicylic acid was started, and the patient responded well clinically. One month later, a repeated colonoscopy confirmed that the lesions including longitudinal ulcers had disappeared. In this report, we describe our experience of this rare case of Behçet’s disease concomitant with colonic longitudinal ulcers and epithelioid granuloma, and discuss the difficulties in making a differential diagnosis, primarily with regard to Crohn’s disease.     

Recurrent aseptic liver abscesses in a patient with Crohn’s disease: True infection or a Crohn’s flare?

A liver abscess is identified as a rare extraintestinal manifestation of Crohn’s disease, with an incidence of approximately 150 in 100,000 patients with this condition. In many of these patients, infectious causes are identified, and the patient’s condition is often noted to improve with antibiotics. An aseptic abscess (AA) is an increasingly recognized entity, especially in patients with inflammatory bowel disease, where repetitive evaluations to identify the infectious cause are futile. The average age of diagnosis for an AA is 29 years. The most common site is the spleen, followed by the lymph nodes and then the liver. In this study, we present a unique case of extensive aseptic liver abscesses extending into the pleural cavity in a young patient with Crohn’s disease.     

Left main dissection conservatively managed with optical coherence tomography guidance

Left main dissection (LMD) is a rare but feared complication of cardiac catheterization. It is usually managed by bailout stent implantation or coronary artery bypass surgery. We describe a case of iatrogenic, retrograde LMD during percutaneous coronary intervention. After covering the retrograde entry of the dissection in the ostial left anterior descending artery (LAD), optical coherence tomography (OCT) showed, that there was no antegrade entry in the left main and that the minimal true lumen area in the left main was 7.2 mm². It was therefore decided to treat the LMD conservatively and reassess the results by angiography 6 months later. At follow‐up angiography, no stenosis or residual dissection in the left main were noted. The patient was doing fine at 1‐year follow‐up. OCT is a valuable tool for assessing coronary artery dissections and may guide the decision, whether to stent or not to stent a dissection. In selected cases LMD may be managed conservatively. © 2013 Wiley Periodicals, Inc.     

Crohn’s disease stricture evaluation and management

Crohn’s disease (CD) is chronic inflammatory disease of the intestinal tract. Majority of Crohn’s disease patients would go on to develop a complicated disease course over time including stricturing and penetrating disease. Stricturing CD requires a multidisciplinary approach between the surgical and medical team for comprehensive management. Despite significant advances in the therapeutic armamentarium for CD, there is no approved medical therapy and none on the horizon that can reverse fibrostenotic disease. Therefore, stricturing CD remains a therapeutic challenge and is associated with considerable morbidity and cost. Recent imaging technique such as MR enterography helps to better delineate stricturing disease. The therapeutic options for fibrostenotic CD comprise of endoscopic balloon dilation and surgical measures. Endoscopic balloon dilation delays the need for surgery, reduces the risk of short bowel syndrome, and has lower complication rate than surgery. The goal of this review is to present a comprehensive overview of the current knowledge, identification, and management of strictures in patient with CD, with a focus on the role of endoscopic therapy.     

Œsocoloplasties itératives pour sténoses caustiques de l’œsophage : place de la résection de l’articulation sternoclaviculaire

The colic graft necrosis is a redoubtable complication of the colon interposition for esophageal replacement. Its frequency varies from 1% to 22% according to the series. The restoring of the digestive continuity is a real problem. We report the observation of a 24-year-old patient admitted for a caustic stenosis of the esophagus, it was a long stenosis which was not dilatable; he underwent a colon interposition for esophageal replacement. Postoperative recoveries were labeled by the occurrence of a respiratory distress syndrome with fever on the second postoperative day. An injected scanner showed a proximal graft necrosis. The patient underwent a revision surgery with resection of 7 cms of necrosed colon, the rest of the graft was retained in the abdomen as a blind colostomy, and an esophagostomy was realized. We used the same graft for second reconstruction. The left clavicle’s head and the manubrium were resected to enlarge the thoracic inlet. The postoperative recoveries were simple. The aim of this work is to underline the difficulty of the second reconstruction in case of necrosis of the colic graft which can require complex surgical procedures and the contribution of the resection of the clavicle’s head and the manubrium, which can allow the use of the same graft.     

Iatrogenic left main coronary artery stenosis after aortic and mitral valve replacement

A case of 48-year old patient, who developed anginal symptoms 3 months after aortic and mitral valves replacement was presented. The patient underwent coronary angiography, which revealed severe left main coronary stenosis. Successful surgery was done with grafting of left anterior descending and circumflex arteries. Opinions on etiology, diagnosis and management of this rare complication are discussed.     

Maladie de Crohn compliquée d’abcès intra-abdominaux : stratégie diagnostique et thérapeutique

Introduction

Intra abdominal abscess in Crohn??s disease is a rare complication. Its management presents diagnostic and therapeutic problems.

Aim of the study

To evaluate our management of patients with intra abdominal abscess as a complication of Crohn??s disease and propose a diagnostic and therapeutic strategy.

Method

Retrospective study of 32 cases of Crohn??s disease complicated by intra abdominal abscess were admitted to our department between 1995 and 2007.

Results

The study examined 10 men (32%) and 22 women (68%), the average age was 31 ± 9.91 years. The abscess inaugurated Crohn??s disease in 10 cases (32%), in the other cases (68%) the diagnosis of Crohn??s disease had already been made. The Crohn??s disease was ileocecal in 31 cases (98%), and colic in one case. The clinical presentation was not specific, local abdominal guarding was found in only one patient (3%). A high level of leucocytes was found in 81% of the cases and a high level of C-reactive protein in all cases (100%). Twenty patients in the study were explored by abdominal ultra sound (62%) which sensibility was about 55% for the abscess diagnosis. An abdominal scan was made on 29 patients (71%) for the abscess diagnosis; the average size of the abscess was about 5.2 cm. The abscess was treated by antibiotherapy In 15 cases (47%) with success in 80% of the cases and in 17 cases (53%) by a radiological percutaneous drainage with success in 89% of the cases. The percutaneous drainage was removed after a mean of 22 ± 16 days. Colonoscopy and barium meal showed an associated intestinal stenosis in 31 cases inducing an intestinal resection. In one case, the stenosis was small and the patient was not operated after the treatment of the abscess; the evolution showed a recidivate abscess after one year. The surgical procedure consisted in: an ileocecal resection in 31 cases, by a laparoscopic approach in 7 cases and in one case a total colectomy with an ileo-rectal anastomosis was performed. Surgical complications occurred in 6 cases (18%)

Conclusion

When an intra abdominal abscess is suspected for patients with Crohn??s disease, the diagnosis approach must be based directly on the abdominal CT scan. The therapeutic approach must be based on a percutaneous drainage first, followed by a resection in the presence of a persistent fistula or intestinal stenosis. This resection could be done by laparoscopic surgery when possible.     

Challenges associated with treatment of left internal mammary artery graft thrombosis

Acute occlusion of the left internal mammary artery (LIMA) graft late after coronary artery bypass grafting surgery is a rare and potentially life‐threatening complication. We describe a case of acute myocardial infarction 19 years after coronary artery bypass graft surgery due to acute occlusion of the distal anastomosis of a LIMA graft to the left anterior descending artery. Aspiration thrombectomy failed to remove the thrombus. Laser thrombectomy caused perforation. After drug‐eluting and covered stent implantation, antegrade TIMI 3 flow was restored with an uneventful postprocedural course.     

Laser recanalisation of coronary arteries by metal-capped optical fibres: early clinical experience in patients with stable angina pectoris

The delivery of laser energy to the coronary circulation by bare optical fibres may cause perforation of the vessel. Experimental studies have shown that this complication can be avoided if the optical fibre is fitted with a metal cap to prevent the potentially dangerous forward projection of the laser beam. This study was performed to assess the feasibility and short term effects of percutaneous coronary laser recanalisation with these modified fibres. Recanalisation of a severe stenosis of the left anterior descending artery was attempted in six patients who were referred for coronary artery bypass grafting. Although the percutaneous technique was used, the laser procedure was performed during coronary bypass surgery before the start of cardiopulmonary bypass to minimise the effects of potential complications. A 1.5 mm diameter metal-capped fibre coupled to an argon laser was advanced percutaneously over a guide wire positioned across the stenosis. In the first patient the delivery of 152 J resulted in the gradual passage of the fibre through a 3 cm long stenosis. Repeat angiography showed a reduction in the severity of the stenosis. In the second patient the delivery of 112 J failed to allow fibre advancement; a further 80 J pulse caused perforation which was repaired. In the remaining four patients the delivery of laser energy in the attempt to traverse the stenosis was limited to less than 90 J. In two of the four patients the severity of stenosis was reduced. No further complications were seen. Percutaneous coronary laser recanalisation with metal-capped optical fibres is feasible but improvements of currently available technology are needed to increase the primary success rate.     

Percutaneous coronary angioplasty in the elderly: a report of 2 cases in patients over 90

Percutaneous transluminal coronary angioplasty is a validated method for coronary revascularization over coronary surgery in elderly patients. We describe two cases in patients in their nineties. Case n. 1: a 95-year-old patient with post-infarction angina that was not controlled well by medical therapy. On admission to our department, the patient was in good hemodynamic condition and a transthoracic echocardiographic examination confirmed normal left ventricular systolic function. Coronary angiography showed a severe calcified stenosis of the left anterior descending coronary artery, which was successfully treated with coronary angioplasty and stenting. After three months, the patient was readmitted because of angina. A new coronary angiogram showed diffuse in-stent restenosis, which was successfully treated with rotational atherectomy and angioplasty. The patient was asymptomatic at follow-up after 6 months. Case n. 2: a 91-year-old patient was admitted for an unstable angina. On admission to our department the patient was in good hemodynamic condition. Coronary angiography showed a severe stenosis of the left anterior descending coronary artery that was successfully treated with angioplasty and stenting. The patient was asymptomatic at 6-month follow-up. These cases show that coronary revascularization can successfully be performed even in patients in their nineties when medical therapy is unsuccessful and the patients are considered at high risk for surgery.     

溃疡性结肠炎的手术指征、手术方式及围手术期管理

溃疡性结肠炎是炎症性肠病（IBD）的一种表现类型,发病部位主要集中在结直肠,其并发症主要为出血、穿孔、癌变及反复发作引起梗阻。溃疡性结肠炎与克罗恩病不同,溃疡性结肠炎是可以通过手术而达到根治的,且手术后的复发率及并发症率都较低,手术对于溃疡性结肠炎的患者有着更重要的意义。而手术指征、手术方式和围手术期的管理与手术的效果及术后患者的生活质量都有着密切的关系,所以对外科医生的经验及技术提出了较高的要求。本文主要集中探讨外科治疗溃疡性结肠炎的手术指征、手术方式及围手术期处理等问题。     

Perforation of the colon by invading recurrent gastrointestinal stromal tumors during sunitinib treatment

The molecular targets of sunitinib are receptor tyrosine kinases （RTKs）, and this drug has also been known to exert blocking effects on the activation of KIT, which is similar to the mechanism of action of imatinib. Moreover, sunitinib has an additional anti-angiogenic effect through its inhibition of the vascular endothelial growth factor receptor activation. We report here a 70-year-old patient diagnosed with a recurrent gastrointestinal stromal tumor （GIST）, which invaded the transverse colon and led to a perforation during sunitinib treatment. A computed tomography scan and 3-dimensional reconstruction showed necrosis of the recurrent hepatic mass and perforation of the invaded transverse colon. After percutaneous drainage of the intraperitoneal abscess, antibiotic treatment and restricted diet, the condition of the patient improved. The present case is the first to report that sunitinib, which is administered to treat GIST resistant to imatinib, can cause unexpected colon perforation and subsequent peritonitis.     

Glycogen storage disease lb and Crohn colitis in a young woman

The occurrence of inflammatory bowel disease in patients with glycogen storage disease Ib is rare (GSD-Ib). We present the case of a young woman with the diagnosis of GSD-Ib Crohn-like colitis developed at age 22. Clinical evaluation revealed severe malnutrition, secondary amenorrhea, leukopenia, neutropenia, dysfunctions of phagocytosis, and subtotal stenosis of the ascending colon. Right hemicolectomy was performed and pathohistologic analysis of the resected bowel showed chronic bowel inflammation consistent with Crohn disease. Clinical status of the patient markedly improved after surgery.     

Deficiency of the intestinal growth factor, glucagon-like peptide 2, in the colon of SCID mice with inflammatory bowel disease induced by transplantation of CD4+ T cells

BACKGROUND: Glucagon-like peptide 2 (GLP-2) is produced in endocrine L-cells of the intestinal mucosa. Recently, GLP-2 was found to stimulate intestinal mucosal growth. Our objective was to study the content of GLP-2 in the large intestine in a murine model of T-cell-induced inflammatory bowel disease. METHODS: Inflammation was induced by adoptive transfer of CD4+ blast T cells from BALB/c mice to SCID mice. The amount of GLP-2 (1-33) was measured with a specific, NH2-terminally directed radioimmunoassay in tissue extracts from the large intestine of transplanted mice developing colitis and from BALB/c and SCID control mice. RESULTS: In the middle and descending colon segments showing the most severe signs of inflammatory lesions in the CD4+ T-cell-transplanted mice, the amount of GLP-2 was significantly lower than in similar colon segments in both untransplanted SCID mice and normal BALB/c mice (P = 0.0013 and 0.0033). In the descending colon the amount of GLP-2 was 6.7 +/- 1.0 pmol/g protein in the CD4+ transplanted mice compared with 68.4 +/- 20.3 and 42.7 +/- 4.3 in the two groups of control mice. Similar findings were made with regard to the contents of the two other proglucagon-derived intestinal peptides, glicentin and GLP-1. CONCLUSION: The amount of GLP-2 is markedly reduced in the colon of mice with a T-cell-induced inflammatory bowel disease histopathologically resembling both Crohn disease and ulcerative colitis. This observation may provide a pathophysiologic rationale for administration of GLP-2 as a trophic factor in inflammatory bowel disease.